Attachment E - Voluntary Self-Certification Forms.pdf

Organization Name:

VOLUNTARY Business Category Self Certification (Check all boxes that apply.)

Self Certifications (Mark X for all that apply)

Small Business Information:

Small Business Concern (SBC):

Small Disadvantaged Business (SDB) Woman‐Owned Small Business (WOSB)

HUBZone Small Business (HUM Zone) Veteran‐Owned Small Business (VOSB)

SBA 8(a) and Small Business Mentor Service‐Disabled Veteran‐Owned Small Business (SDVOSB) Protégé Program 8(a) Not Applicable

Large Business Concern (LBC):

Minority‐Owned Bus. Enterprise (MBE) Woman‐Owned Business Enterprise (WBE)

Not Applicable

Business Characteristics (Mark X for all that apply)

Please select any appropriate characteristics for your business below.

*Veteran‐Owned Asian‐Owned *Woman‐Owned Black‐Owned Located in Colorado *Disabled‐Owned (DOBE) Benefits Offered: Health insurance to employees

Employee‐Owned Benefits Offered: Paid time off Immigrant‐Owned Environmentally sustainable practices used Latino‐Owned Hire people with barriers to employment

*LGBTQBE‐Owned (LGBTBE) Pay a living wage *Minority‐Owned Social Enterprise Native American‐Owned Unionized workers Refugee‐Owned Other Please provide details in the box below:

*Certification available

Business Size (# Full Time Employees)

1‐25 Employees 251‐500 Employees

26‐100 Employees 501‐1000 Employees

101‐250 Employees Over 1000 Employees

In an effort to help us understand and measure Denver Health's diverse vendor relationships, you are invited to provide additional information about your company. We are reviewing levels of participation by women, minorities, small businesses, local businesses, and other impacted groups doing business with Denver Health. Please provide the appropriate ownership category for your company, as well as any characteristics of your business you would like to share.

"Owned" in the context below means a business that is at least 51 percent owned by an individual(s) who also control(s) and operate(s) it.

"Control" in this context means exercising the power to make policy decisions.

"Operate" means actively involved in the day‐to‐day management. If your business is jointly owned by both men and women, or is a large publicly held corporation, please check the box labeled "Not Applicable".

A Small Business is a business that is organized for profit, is independently owned and operated and not dominant in their field of operation.

Rev 2/24/2022

CO Alumni-Owned

Additional Descriptive Information

CO Alumni‐Owned ‐ A business owned by an alumna/alumnus of colleges and universities located in the state of Colorado.

Disabled‐Owned ‐ (DOBE) A disability‐owned business enterprise is a for profit business that is at least 51% owned, managed and controlled by a person with a disability.

(From https://disabilityin.org/what‐we‐do/supplier‐diversity/)

Large Business Concern ‐ (LBE) An organization that exceeds the small business size code standards established by the SBA as set forth in the Code of Federal Regulations, Title 13, Part 121.

LGBTQ‐Owned ‐ Be at least fifty‐one percent (51%) owned, operated, managed, and controlled by an LGBT person or persons who are either U.S. citizens or lawful permanent residents. (From https://www.nglcc.org/get‐certified)

Living Wage ‐ The minimum income needed to meet basic needs for an individual. The remuneration received for a standard workweek by a worker in a particular place sufficient to afford a decent standard of living for the worker and her or his family. Elements of a decent standard of living include food, water, housing, education, health care, transportation, clothing, and other essential needs including provision for unexpected events.

(From Globallivingwage.org)

Located in Colorado ‐ The business must be registered with the Colorado Secretary of State.

Minority ‐ An individual who is a U.S. citizen with at lease one quarter of the following: Aftican‐American/Black, Asian‐Indian, Asian‐Pacific, Hispanid/Latin‐American, Native American.

(From https://nmsdc.org/mbes/what‐is‐an‐mbe/)

Minority‐Owned ‐ A business with at least 51% minority ownership and management of the day‐to‐day operations.

Social Enterprise ‐ A social enterprise is an organization or initiative that marries the social mission of a non‐profit or government program with the market‐driven approach of a business.

(From https://www.sbventures.org/social‐enterprise‐alliance) Typically they reinvest or donate profits for environmental or social change.

Small Business Concern ‐ (SBE) an organization that falls within the small business net worth and code standards established by the SBA as set forth in the Code of Federal Regulations, Title 13, Part 121.

Veteran‐Owned ‐ At least 51% of the business must be directly and unconditionally owned by one or more Veteran(s) or Service‐disabled Veteran(s). (From https://www.va.gov/osdbu/verification/)

Woman‐Owned ‐ At least 51% owned and controlled by women who are U.S. citizens. Have women manage day‐to‐ day operations who also make long‐term decisions.

(From https://www.sba.gov/federal‐contracting/contracting‐assistance‐programs/women‐owned‐small‐business‐ federal‐contracting‐program#section‐header‐6)